Diabetes Care
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Published online February 15, 2007
Diabetes Care 30:1283-1285, 2007
DOI: 10.2337/dc06-1657
© 2007 by the American Diabetes Association
This Article
Right arrow Extract Freely available
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
dc06-1657v1
30/5/1283    most recent
Right arrow Purchase Article
Right arrow View Shopping Cart
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Tunceli, K.
Right arrow Articles by Vijan, S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Tunceli, K.
Right arrow Articles by Vijan, S.
Social Bookmarking
Add to CiteULike   Add to Del.icio.us   Add to Digg   Add to Reddit   Add to Technorati  
What's this?

Epidemiology/Health Services/Psychosocial Research
Brief Report

Glycemic Control and Absenteeism Among Individuals With Diabetes

Kaan Tunceli, PHD1, Cathy J. Bradley, PHD2, Jennifer E. Lafata, PHD1, Manel Pladevall, MD, MS1, George W. Divine, PHD3, Allen C. Goodman, PHD4 and Sandeep Vijan, MD5

1 Center for Health Services Research, Henry Ford Health System, Detroit, Michigan
2 Health Administration, Virginia Commonwealth University, Richmond, Virginia
3 Department of Biostatistics and Research Epidemiology, Henry Ford Health System, Detroit, Michigan
4 Department of Economics, Wayne State University, Detroit, Michigan
5 Ann Arbor Veterans Affairs Health Services Research and Development, and the Department of Internal Medicine and Michigan Diabetes Research and Training Center, University of Michigan School of Medicine, Ann Arbor, Michigan

Address correspondence and reprint requests to Dr. Tunceli, 1 Ford Pl., Suite 3A, Detroit, MI 48202. E-mail: ktuncel1{at}hfhs.org


   INTRODUCTION
TOP
 INTRODUCTION
RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
 References
 
The associations between adverse labor market outcomes and diabetes/diabetes complications are well described (1–8). Clinical guidelines have recommended standards for glycemic, lipid, and blood pressure control (9) that have been shown to prevent or delay the onset and progression of diabetes complications (10–16). It is possible that control of these symptoms can reduce absenteeism in employed patients. Two studies have examined the relationship between glycemic control and labor market outcomes including absenteeism (17,18), and this study adds to that literature by examining the cross-sectional associations between absenteeism from work and glycemic, lipid, and blood pressure control among individuals with diabetes.


   RESEARCH DESIGN AND METHODS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
RESULTS--
 CONCLUSIONS--
 References
 
Patients were identified as having diabetes (n = 27,407) from administrative data available within a medical group in southeast Michigan between 1 June 2003 and 31 May 2004. From these patients, we selected those who were tested for A1C during the prior 12 months and aged 30–64 years (n = 11,324). Next, we drew a random sample of 1,000 patients stratified by glycemic control level (A1C <7.0, 7.0–7.99, 8.0–8.99, 9.0–9.99, or ≥10.0%). Several exclusions were made, including subjects who had died (n = 5), absence of a physician from whom to obtain permission for patient contacts (n = 72), patients’ inclusion in other research studies (n = 132), physician refusal (n = 46), incorrect diagnosis (n = 5), and language barrier (n = 13). The final sample comprised 727 patients for a telephone survey and had an overall participation rate among eligible subjects of 59% (n = 427). The response rate for eligible subjects who were contacted was 81% (n = 525).

The primary outcome was hours absent from work for any reason during the 4 weeks before the survey and was reported by 218 of 233 employed patients. The explanatory variables of interest were A1C and LDL cholesterol, obtained through the automated laboratory data, and systolic and diastolic blood pressure levels, extracted from the medical records using computerized data collection forms. For patients with more than one test result during the 12 months before the telephone survey, we used the arithmetic mean value of A1C, LDL cholestorol, and systolic and diastolic blood pressure. We controlled for age, sex, race, education, marital status, comorbidities, BMI, years since diagnosis, insulin use, occupation type (white collar, blue collar, and service sector), and usual weekly hours worked.

We estimated a probit model for the probability of having any hours absent from work and a tobit model for hours missed from work using data from employed individuals. The tobit model accounts for 0 values that occur when a significant portion of patients do not report absenteeism (53%). We performed separate analyses for men and women given their differences in workforce participation, job type, and job attachment (19). Respondents with higher A1C values and male subjects were less likely to participate in the survey. Thus, we weighted coefficients from multivariable models by their inverse probabilities of survey participation. We report unweighted results because weighting did not change the results in either magnitude or statistical significance.


   RESULTS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
CONCLUSIONS--
 References
 
Patients with diabetes in our sample were 53 years old on average, 54% female, and nearly evenly split between white and African-American race/ethnicity (49 and 45%, respectively). The employment rate (55%) among the study participants was comparable with the estimates in previously published studies of patients with diabetes (1,4,7,8). In pairwise comparisons, on average, both men and women with higher A1C levels reported a greater number of hours absent compared with those with lower A1C levels (results not shown), although patients did not differ by glycemic control in terms of employment status or usual weekly hours worked. For example, relative to employed patients with A1C <7%, employed men and women with A1C ≥10% lost an additional 5.4 h (P < 0.05) and 4.4 h (P < 0.01), respectively, in the past 4 weeks.

Table 1 presents two models. The first is a probit model predicting the probability of being absent from work ≥1 h, and the second predicts the number of hours absent from work. For ease of interpretation, the probit estimates are translated into derivatives of the probability (e.g., marginal effects) of being absent with respect to the independent variables. The marginal effects (unconditional expected values), as measures of total impact of individual risk factors on hours absent including observations with 0 values, are also reported for the tobit model, which takes into account that many employees (53%) did not report absenteeism.


View this table:
[in this window]
[in a new window]

  		Table 1— Multivariate models for probability of absenteeism and actual hours absent in the past 4 weeks

 
Among men, those with A1C between 8 and 9% and those with A1C ≥10% were more likely to miss work (marginal effect [ME] 32 percentage points, P < 0.05 and 35 percentage points, P < 0.05, respectively). Men with A1C between 8 and 9% furthermore lost ~6 h on average (P < 0.05) compared with men with A1C <7%. Men with LDL cholesterol ≥100 mg/dl were more likely both to miss work (26 percentage points, P < 0.05) and to report more hours absent (3.8 h, P < 0.10) relative to men with LDL cholesterol <100 mg/dl.

Among women, those with A1C ≥10% were 62 percentage points more likely to report any absenteeism (P < 0.01). Women with A1C between 9 and 10% and women with A1C ≥10% lost an additional 7.9 h (P < 0.01) and 10.3 h (P < 0.01), respectively, compared with those with A1C <7%.

In other multivariable models, usual weekly hours worked and the difference between weekly hours worked and hours absent per week did not vary by level of any risk factor control (results not shown).


   CONCLUSIONS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
References
 
As the prevalence of diabetes increases (20,21), the number of individuals with diabetes among the working population will rise. With projections that as many as one in three people born in 2000 will develop diabetes (22), the implications of diabetes on labor market outcomes are enormous for patients, families, employers, and policy makers.

Our study provides a cross-sectional assessment of the potential impact of diabetes control (glycemic, lipid, and blood pressure control) on absenteeism among those with diabetes. Poor glycemic control, in some cases, was associated with increased absenteeism. Among men, poor lipid control was also associated with absenteeism. Such findings imply that the adverse impact of diabetes on productivity might be partially reduced through improved control of modifiable risk factors.

Four important limitations are noted. First, the cross-sectional assessment of the relationship between diabetes control and absenteeism is not sufficient to estimate causal paths from control of risk factors to work productivity. Multiple measures over time are required for causal interpretations. Second, the study lacked information on medications taken for hyperglycemia, hypertension, and hyperlipidemia. Therefore, we were not able to account for treatment effects of these medications on outcomes. Third, a dose-response relationship between glycemic control categories and absenteeism (e.g., increasing absenteeism with increasing A1C categories) was not observed. Fourth, usual weekly hours worked or the difference between usual weekly hours worked and hours absent per week did not vary by level of any risk factor control; thus, our findings should be cautiously interpreted.

Given that access to health care is usually obtained through employer-provided health insurance plans in the U.S. and given that employers search for ways to control health care costs, documenting potential economic gains in the workplace (e.g., reduced absenteeism) from improved clinical control of diabetes may encourage employers, health plans, and policy makers to further their attempts to improve the quality of care delivered to patients with diabetes. The returns from preventing productivity losses might substantially offset costs of implementing such programs.


   Acknowledgments
 
This research was supported by the Institute for Population Sciences, Health Assessment, Administration, Services, and Economics (INPHAASE), which is a coordinating institute between faculties of Wayne State University (WSU) and Henry Ford Health System (HFHS). The contents are solely the responsibility of the authors and do not necessarily represent the official views of INPHAASE.

The authors gratefully acknowledge the assistance of Kemeng Li and Manish Patel (WSU) and Deneil M. Kolk and Hugo Xi (HFHS).


   Footnotes
 
Published ahead of print at http://care.diabetesjournals.org on 15 February 2007. DOI: 10.2337/dc06-1657.

A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C Section 1734 solely to indicate this fact.

Received for publication August 4, 2006. Accepted for publication January 31, 2007.


   References
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
 References
 

  1. Kahn ME: Health and labor market performance: the case of diabetes. Journal of Labor Economics 16:878–899, 1998
  2. Kraut A, Walld R, Tate R, Mustard C: Impact of diabetes on employment and income in Manitoba, Canada. Diabetes Care 24:64–68, 2001[Abstract/Free Full Text]
  3. Mayfield JA, Deb P, Whitecotton L: Work disability and diabetes. Diabetes Care 22:1105–1109, 1999[Abstract/Free Full Text]
  4. Ng YC, Jacobs P, Johnson JA: Productivity losses associated with diabetes in the U.S. Diabetes Care 24:257–261, 2001[Abstract/Free Full Text]
  5. Bastida E, Pagan JA: The impact of diabetes on adult employment and earnings of Mexican Americans: findings from a community based study. Health Econ 11:403–413, 2002[Medline]
  6. Brown HS 3rd, Pagon JA, Bastida E: The impact of diabetes on employment: genetic IVs in a bivariate probit. Health Econ 14:537–544, 2005[Medline]
  7. Vijan S, Hayward RA, Langa KM: The impact of diabetes on workforce participation: results from a national household sample. Health Serv Res39:1653–1669, 2004[Medline]
  8. Tunceli K, Bradley CJ, Nerenz D, Williams LK, Pladevall M, Elston LJ: The impact of diabetes on employment and work productivity. Diabetes Care 28:2662–2667, 2005[Abstract/Free Full Text]
  9. American Diabetes Association: Standards of medical care in diabetes: 2006 (Position Statement). Diabetes Care 29(Suppl. 1):S4–S42, 2006
  10. Vijan S, Hayward RA: Treatment of hypertension in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care. Ann Intern Med 138:593–602, 2003[Abstract/Free Full Text]
  11. UK Prospective Diabetes Study Group: Cost effectiveness analysis of improved blood pressure control in hypertensive patients with type 2 diabetes: UKPDS 40. BMJ 317:720–726, 1998[Abstract/Free Full Text]
  12. CDC: Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes. JAMA 287:2542–2551, 2002[Abstract/Free Full Text]
  13. Vijan S, Hayward RA: Pharmacologic lipid-lowering therapy in type 2 diabetes mellitus: background paper for the American College of Physicians. Ann Intern Med 140:650–658, 2004[Abstract/Free Full Text]
  14. Grover SA, Coupal L, Zowall H, Dorais M: Cost-effectiveness of treating hyperlipidemia in the presence of diabetes: who should be treated? Circulation 102:722–727, 2000[Abstract/Free Full Text]
  15. UK Prospective Diabetes Study (UKPDS) Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352:837–853, 1998[Medline]
  16. The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977–986, 1993[Abstract/Free Full Text]
  17. Testa MA, Simonson DC: Health economic benefits and quality of life during improved glycemic control in patients with type 2 diabetes mellitus: a randomized, controlled, double-blind trial. JAMA 280:1490–1496, 1998[Abstract/Free Full Text]
  18. Von Korff M, Katon W, Lin EH, Simon G, Ciechanowski P, Ludman E, Oliver M, Rutter C, Young B: Work disability among individuals with diabetes. Diabetes Care 28:1326–1332, 2005[Abstract/Free Full Text]
  19. Altonji JG, Blank R: Race and gender in the labor market. In Handbook of Labor Economics. Ashenfelter O, Card D, Eds. Amsterdam, Elsevier Science, 1999, p. 3144–3259
  20. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP: The continuing epidemics of obesity and diabetes in the United States. JAMA 286:1195–1200, 2001[Abstract/Free Full Text]
  21. Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, Marks JS: Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA289:76–79, 2003
  22. Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF: Lifetime risk for diabetes mellitus in the United States. JAMA 290:1884–1890, 2003[Abstract/Free Full Text]

Add to CiteULike CiteULike   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to Technorati Technorati    What's this?



This Article
Right arrow Extract Freely available
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
dc06-1657v1
30/5/1283    most recent
Right arrow Purchase Article
Right arrow View Shopping Cart
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Tunceli, K.
Right arrow Articles by Vijan, S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Tunceli, K.
Right arrow Articles by Vijan, S.
Social Bookmarking
Add to CiteULike   Add to Del.icio.us   Add to Digg   Add to Reddit   Add to Technorati  
What's this?

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
Diabetes Diabetes Care Clinical Diabetes Diabetes Spectrum